NIH consensus and the < 8.8 pound baby.

[hildare]

does anyone have real experience with vbac of an over that recommendation sized baby? 

i've waffled between feeling like a vbac's just out of reach, and wanting to try, to being concerned that this is going to make the difference. 

dd was 10 lbs at birth.  i'm early into this pregnancy, ob is supportive of the vbac but did mention size was an issue.  (fwiw, size was not the issue with dd, and same ob indicated that i was structurally able to push out a big babe-- waters breaking and no dilation were the problem)

[kitkat5505]

I have friend's that have VBAC'd babies 10lb1oz and 10lb9oz, after being told their previous smaller babies were too big. My 1st VBAC baby was 8lb14oz and a MW told me I could probably easily push out a 10lb baby.

[LisaSedai]

My C/S baby was 7 lbs 14 oz and  my VBAC baby was 9 lbs 14 oz. There are several 9 -10 lbs babies on my ICAN board, I believe one HBAC was actually 11 lbs.  Baby fat squishes. Many providers are scared to death of big babies and practically ram a ERCS down your throat- and some will say they support VBAC until right at the end of things when it's too late to switch providers. U/S are notorious for being "off" as far as weight guessing is concerned. The day before I had my C/S baby, the U/S done ( to help steer me to a C/Section I am sure) estimated his weight as over 9 lbs. Some doctors want to induce you early or want to give you a ERCS the day you reach 40 weeks if the are afraid the baby is going to be big. I've seen some VBAC stories on youtube of 10 lbs babies. The main thing is to get a provider who is willing to support your VBAC efforts. Good luck!

ETA: I just noticed from your siggy you are in GA... come visit the Atlanta ICAN group!

[roadfamily6now]

Yes, VBACed a 8lb 13oz baby, a 10lb 4oz baby and a 10lb 2oz baby.

My c-section baby was 7lbs 13oz (breech)

[kim_nz]

My c/s baby (c/s due to position and failed induction) was my smallest at 7lbs 12oz. My Vbac babies were 9lbs, 8lbs 7oz, 8lbs 10oz and 9lbs 12oz.

[Mom2M]

I had 2 VBAC babies. The one after my first C section was 9 pounds 1 oz. The baby after my second c section was 9 pounds 6 oz.
u/s estimates are very inaccurate in my experience. My second c section baby was estimated to be over 8 pounds and really was 6 pounds 1 oz. My second VBAC baby was estimated to be about 7 and 1/2 pounds and was 9 pounds 6 oz. lol

[SilverFish]

just a little anecdata about scans predicting size.

my sister just had a second c/s for "suspected big baby" at 39+5 w. her last was 10lb6oz and a emerg c/s. so this time she had scan after scan to check for size. they were saying all along that it was a huge baby, she'd have to have a c/s again. the second to last scan, the dr said, wait, it's not big after all, we'll let you go to your due date before deciding.

at her last appointment, they did another scan (why, i'm not sure) and suddenly the baby had "put on at least 1 kg of weight, you'll have to have a section either tomorrow or the day before your due date." well, she went for the c/s and the baby was born at 3.5 kg or 8lbs.

everyone seems to have conveniently forgotten that this baby either magically added 1 kg of weight in a week, meaning at the 2nd last scan she was a mere 2.5 kg (the exact weight of my preterm baby, 5lb10oz), or more likely, the scans do a pretty poor job of accurately predicting birth weight. she had the complicating factor of gestational diabetes, so a c/s may have been unavoidable anyway, but i would be running away from any dr trying to tell me that a size was a major factor in "letting" me attempt a VBAC.

[JoyFilled]

Originally Posted by hildare 

waters breaking and no dilation were the problem

Thanks for this post.  My DD was 10lbs 6oz and I had the same problem as you.  All along this pregnancy I was told VBAC was an option and to just not eat too much.  I am due today.  3 days ago I met with an OBS and he said that this baby was huge already.  He said that I for sure could and should try but at any sign of things not progressing I should just go for the c-section because the baby would not fit.

I came here looking for success stories for births of larger babies.  I know that the book "Silent Knife" says 60% or more of their VBAC moms were overdue and 85 out of 105 had larger babies then their c-section baby.  I just keep thinking about those success stats.

[hildare]

joyfilled, i hope that you are able to get your VBAC and we are reading your happy birth story soon!  i guess for you laboring at home as long as possible is the key?  <3

[hildare]

Originally Posted by SilverFish 

just a little anecdata about scans predicting size.

my sister just had a second c/s for "suspected big baby" at 39+5 w. her last was 10lb6oz and a emerg c/s. so this time she had scan after scan to check for size. they were saying all along that it was a huge baby, she'd have to have a c/s again. the second to last scan, the dr said, wait, it's not big after all, we'll let you go to your due date before deciding.

at her last appointment, they did another scan (why, i'm not sure) and suddenly the baby had "put on at least 1 kg of weight, you'll have to have a section either tomorrow or the day before your due date." well, she went for the c/s and the baby was born at 3.5 kg or 8lbs.

everyone seems to have conveniently forgotten that this baby either magically added 1 kg of weight in a week, meaning at the 2nd last scan she was a mere 2.5 kg (the exact weight of my preterm baby, 5lb10oz), or more likely, the scans do a pretty poor job of accurately predicting birth weight. she had the complicating factor of gestational diabetes, so a c/s may have been unavoidable anyway, but i would be running away from any dr trying to tell me that a size was a major factor in "letting" me attempt a VBAC.

i absolutely understand that it's very difficult to predict size/weight from u/s.  however, it's statistically unlikely that a second baby is going to be smaller/less heavy than the first.  the concern i'm having at this point is with the NIH recommendation and indication that a babe over 8.8 lbs increases risk of rupture.  when my ob first mentioned it, i had no idea what he was talking about, but after reading the NIH stuff, it makes me worry (because i'm pretty sure that baby #2 just won't be smaller than my 10 pound baby #1.  i didn't have gd or anything, at least according to the diagnostics- wasn't even close.)

i like these success stories, mamas!  keep em coming!  <3

[Lish]

While it doesn't specifically mention VBAC in relation to ACOGs c-section recommendations for fetal macrosomia I thought some of you might find this interesting...

Majority of ACOG Recommendations for Patient Care Found to Be Based on Opinion and Inconsistent Evidence

WASHINGTON, D.C. (August 15, 2011)—A study published this month in Obstetrics & Gynecology, the journal of the American College of Obstetricians and Gynecologists, found that barely one-third of the organization’s clinical guidelines for OB/GYN practice meet the Level A standard of “good and consistent scientific evidence.” The authors of the study found instead that the majority of ACOG recommendations for patient care rank at Levels B and C, based on research that relies on “limited or inconsistent evidence” and on “expert opinion,” both of which are known to be inadequate predictors of safety or efficacy.

“The fact that so few of the guidelines that govern routine OB/GYN care in this country are supported by solid scientific evidence—and worse, are far more likely to be based on anecdote and opinion—is a sobering reminder that our maternity care system is in urgent need of reform,” said Katherine Prown, PhD, Campaign Manager of The Big Push for Midwives. “As the authors of the study remind us, guidelines are only as good as the evidence that supports them.”

ACOG Practice Bulletin No. 22 on the management of fetal macrosomia—infants weighing roughly 8 ½ lbs or more at birth—illustrates the possible risks to mothers and babies of relying on unscientific clinical guidelines. The only Level A evidence-based recommendation on the delivery of large-sized babies the Bulletin makes is to caution providers that the methods for detection are imprecise and unreliable. Yet at the same time, the Bulletin makes a Level C opinion-based recommendation that, despite the lack of a reliable diagnosis, women with “suspected” large babies should be offered potentially unnecessary cesarean sections as a precaution, putting mothers at risk of surgical complications and babies at risk of being born too early.

“It’s no wonder that the cesarean rate is going through the roof and women are seeking alternatives to hospital-based OB/GYN care in unprecedented numbers,” said Susan M. Jenkins, Legal Counsel of The Big Push for Midwives. “ACOG’s very own recommendations give its members permission to follow opinion-based practice guidelines that have far more to do with avoiding litigation than with adhering to scientific, evidence-based principles about what’s best for mothers and babies.”

http://journals.lww.com/greenjournal/Abstract/publishahead/Scientific_Evidence_Underlying_the_American.99978.aspx

[liberal_chick]

My c/s baby was 2 pounds, 14 ounces (c/s for a ton of reasons, no labor) and my HBACs were 9 pounds even and 9 pounds, 8 ounces.  Long labors, but no trouble pushing.

[HappyMonkey]

my home birth was 9 lbs 3 ounces and a happy easy birth. I have heard of people with 12 lb + babies easy with no tears. Crazy to imagine people pushed to have c-sections for big babies when ultrasounds are so inaccurate.

[LiLStar]

I don't think its true that large babies increase the risk of rupture. It makes sense that it would if you think about it, but I haven't heard any evidence that its true. In fact, research has shown that even vbacing with multiples doesn't increase the risk of rupture. Check THIS out: http://www.drmomma.org/2010/01/atlanta-mom-births-triplets-via-vbac.html thats over 14lbs of baby if my math is right! 

For personal experience, my c-section was for an 8lb 14oz baby. I dilated and pushed for HOURS but she wasn't positioned well. My HBAC baby was 10lbs 2oz, no tears :)

[LisaSedai]

Lil Star posted a link about the VBAC triplet girls in Atlanta, since then there were VBAC triplet boys born there as well. Dr T does a couple VBAC twins a year too. It's usually about the OB's comfort level than any scientific facts and alot of OB's are afraid of big babies.

[Monkey Keeper]

Originally Posted by hildare 

ob is supportive of the vbac but did mention size was an issue.  (fwiw, size was not the issue with dd, and same ob indicated that i was structurally able to push out a big babe-- waters breaking and no dilation were the problem)

Your c/s situation is similar to mine, though I'd already walked away from a pit induction (I do not respond well to pit) and had had the dreaded weight estimate since I was post-dates and had consented to a BPP. My c/s babe was 9lb, 8oz.

With my VBAC, there was mention of "big baby". I calmly told the OB I expected a 10lber and that I knew I could do it. It never came up again, even when a growth estimate (part of an u/s to prep for a version; he turned on his own) put him at nearly 8lbs just past 36w. In fact, my OB was the first to say that late term u/s are notoriously wrong, and he probably was a pound smaller than that. Of course measuring behind in fundal height helps ;)  There was a bit of hubub about the combination of baby size plus polyhydramnios, but since my fundal height was so normal, and I was okay with it, it wasn't even close to a deal breaker.

DS was badly malpositioned which led to a long, long labor. But he was born with just a few pushes at 9lb, 5oz :)

Soooo....he was a boy AND a subsequent gestation, and he still was a few ounces smaller than his sister!!  There's no guarantee that subsequent babies are bigger; I have a good friend whose 2nd was nearly 10lbs, and her third was barely 7.
 

[JoyFilled]

hildare - thanks for the encouragement.  I am 3 days overdue now.

[ablepearl]

My c-section baby was 7 lb 3 oz.  My first VBAC was 9 lb 14 oz, they did an external version with him at 37.5 weeks, he probably weighed at least 8 lb 8 oz at that time.  VBAC#2 was only 8 lb 15 oz and VBAC#3 was even smaller at 8lb 4.5 oz.  There is no hard and fast rule that subsequent babies are larger!  My mom's biggest baby was her 4th at 10 lb 9oz, then she had an 8 pounder followed by a 9 pounder and a 7 pounder (although the last one was a month early, so who knows how big he *could have been.)

Have you seen this? http://www.youtube.com/watch?v=roFVkDV45MM

[Devaskyla]

My babies have gotten smaller each time. I'm far from the only person I know to have that happen.
 

Originally Posted by hildare 

i absolutely understand that it's very difficult to predict size/weight from u/s.  however, it's statistically unlikely that a second baby is going to be smaller/less heavy than the first. 

The evidence actually shows that the size of the baby has zero effect on the risk of rupture. I'm afraid it was a few years ago I read they study & I don't have a link, but baby size has no bearing on rupture risk.

I actually know a woman who just had a twin VBAC with an 8lb & a 7lb baby. That would put way more pressure on the uterus than a single baby, even a 10 or 12 pound one.
 

Originally Posted by LiLStar 

I don't think its true that large babies increase the risk of rupture. It makes sense that it would if you think about it, but I haven't heard any evidence that its true. In fact, research has shown that even vbacing with multiples doesn't increase the risk of rupture. Check THIS out: http://www.drmomma.org/2010/01/atlanta-mom-births-triplets-via-vbac.html thats over 14lbs of baby if my math is right! 

For personal experience, my c-section was for an 8lb 14oz baby. I dilated and pushed for HOURS but she wasn't positioned well. My HBAC baby was 10lbs 2oz, no tears :)

[hildare]

i'm adding to my original post something i came across in my research.  i thought it might be helpful if anyone else is searching for this information, too...  LINK to the article

Uterine Rupture in Pregnancy / Author: Gerard G Nahum, MD, FACOG, FACS; Chief Editor: David Chelmow, MD

it's an article that is a literature review from:

peer-reviewed literature was searched using the PubMed, Medline, and Cochrane databases for all relevant articles published in the English language. The search terms were uterine rupture, pregnancy and prior cesarean section, vaginal birth after cesarean, VBAC, trial of labor (TOL), trial of labor after cesarean (TOLAC) uterine scar dehiscence, and pregnancy and myomectomy. Standard reference tracing was also used.

Articles published from 1976-2010 that described the incidence of uterine rupture and that included sufficient information regarding the authors' definitions of uterine rupture and of uterine-scar dehiscence were incorporated for review. All studies were observational or reviews. A total of 109 published articles were included for data extraction and analysis.

here's the relevant info to this thread, though the whole article is pretty interesting. 

Fetal macrosomia

Elkousy et al found that, in 9,960 women who underwent a TOL after 1 previous cesarean delivery, the risk of uterine rupture was significantly greater for fetuses that weighed >4000 g (2.8%) than in those weighing < 4000 g (1.2%; RR 2.3, P < .001). For women with 1 previous cesarean delivery and no previous vaginal deliveries, the uterine rupture rate was 3.6% for women with a fetal weight of >4000 g compared to women with a fetal weight of < 4000 g (RR 2.3, P < .001).^[69]

Zelop et al reported that the rate of uterine rupture for women delivering neonates weighing >4000 g was 1.6% versus 1% for newborns ≤4000 g, but that the difference was not statistically significant (P =0.24).^[70] More recently, Jastrow et al showed that birth weight was directly correlated with the rate of uterine rupture, with uterine rupture rates of 0.9%, 1.8%, and 2.6% for birth weights of < 3500 g, 3500-3999 g, and ≥4000 g, respectively (P < .05).^[71]